Biomarker of brainstem activity during CPR of prognostic value

Gasping may be a good sign during resuscitation for out-of-hospital cardiac arrest (OHCA), as it was linked to better survival chances in an observational study.

Regardless of the first recorded rhythm, about 20% of patients who gasped during or before CPR were still alive 1 year later with favorable neurological outcomes (Cerebral Performance Category scores [CPC] of 1 or 2), versus just 3.7% of those who did not show this breathing pattern (adjusted OR 3.94, 95% CI 2.09-7.44).

The natural reflex -- a marker for the presence of brainstem activity, according to researchers led by Guillaume Debaty, MD, PhD, of Pôle Urgences Médecine Aigue in France -- was observed in 10% of OHCA cases. Their study was published in the September 19 issue of Journal of the American College of Cardiology, now online.

Patients who gasped and had a shockable initial recorded rhythm were a "remarkable" 57 times more likely to achieve the favorable outcome (95% CI 23.49 to 136.92), the authors noted.

"These findings underscore the importance of not terminating resuscitation prematurely in gasping patients and the need to routinely recognize, monitor, and record data on gasping in all future cardiac arrest trials and registries," Debaty's group concluded. "The new findings also lead us to question whether it may be harmful to suppress gasping pharmacologically during CPR."

"The implications of their findings should be heeded. Recognizing that gasping is an early sign of cardiac arrest is of utmost importance. This knowledge should be emphasized during CPR training, so that bystanders do not misinterpret gasping as normal breathing," according to Gordon Ewy, MD, of Tucson's University of Arizona College of Medicine, and Paul Armstrong, MD, of the University of Alberta in Edmonton, Canada, in an accompanying editorial.

"However, it should be emphasized, as observed in the current study[,] that in the absence of adequate CPR, gasping is short lived and declines rapidly as minutes elapse from call to first response," they wrote.

Survival with good CPC scores was less likely with:

Younger age (adjusted OR 0.57 for each standard deviation, 95% CI 0.43-0.76)

Shorter CPR duration (adjusted OR 0.31, 95% CI 0.19-0.51)

Lower epinephrine dosage (adjusted OR 0.47, 95% CI 0.25-0.87)

Debaty and colleagues pulled data on gasping from a previous randomized trial of standard versus active compression-decompression CPR. They included 1,888 subjects enrolled from 2007 to 2009 (mean age 64 years, 63% men).

Being an unplanned secondary analysis, the study could have residual confounding despite multivariable adjustment. On baseline, OHCA patients who gasped were more likely to have a witnessed cardiac arrest, an initial cardiac rhythm of VF/VF or pulseless electrical activity, return of spontaneous circulation, and an elevated level of consciousness during pre-hospital CPR. They also had shorter CPR start times.

The original trial was funded by an NIH grant and Advanced Circulatory Systems.

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